Oceanside Care Center Inc
August 6, 2018 Complaint Survey

Standard Health Citations

FF11 483.12(a)(1):FREE FROM ABUSE AND NEGLECT

REGULATION: §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 6, 2018
Corrected date: September 21, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during an abbreviated survey, (Complaint # NY 263) the facility did not ensure resident rights for one of three residents reviewed for neglect (Resident #1). Specifically, the Certified Nursing Assistant (CNA#1) did not follow the plan of care of using two-persons assistance while utilizing a mechanical lift for the resident. The strap of the mechanical lift pad came off and the resident fell to the floor. The findings were: The facility policy titled Prohibition of Abuse, Neglect, and Mistreatment, or Misappropriation of Property/Screening of Employees dated 1/4/2017 defined neglect as the failure of the facility and its employees to provide goods and services to a resident that are necessary to attain or maintain their highest practicable level of physical, mental and psychosocial wellbeing. The Undated policy on Mechanical Lift documented to utilize two people while using the mechanical lift. Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data set 3.0 (MDS-an assessment tool) dated 7/20/2108 documented severely impaired cognition for the resident. The resident required two persons total dependence for transfers and bed mobility. The resident used a Geri recliner as an assistive device. The Comprehensive Care Plan (CCP) titled risk for falls dated 5/27/18 documented the resident needed a mechanical lift and two persons total assistance with the transfer. The Certified Nursing Assistant Clinical Accountability Record dated (MONTH) (YEAR) documented resident#1 to be transferred using a mechanical lift with two persons assistance. The personnel record for the Certified Nursing Assistant (CNA #1) documented a Hoyer lift competency dated 1/16/18 signed by CNA #1 with a return demonstration of accurate mechanical lift transfer by the CNA (#1). CNA #1 was suspended for two weeks. The facility Summary of Investigation dated 7/19/18 documented at around 10:30AM resident was observed lying on the floor with her body lying across the legs of the mechanical lift. The mechanical lift pad was still hooked on the machine with one strap not connected to the left lower side of the strap attachment. Body check was completed, an abrasion to her right elbow was noted. Upon interview and re-enactment from the CNA (#1), she stated she hooked up all canvas pad straps and started lifting the resident in the mechanical lifter, she did not wait for a second person to be in position to assist her. The strap of the sling (pad) came off and the resident slipped out of the pad onto the base of the mechanical lift. The CNA was suspended for a few days due to not following the plan of care for the resident, and she also did not properly hook (secure) the strap of the sling (pad). CNA#2 was interviewed on 7/26/18 at 11:50AM and stated he was coming off from his break walking down the hallway and noticed CNA#1 was attempting to lift Resident #1 via the mechanical lift by herself. At that time, he stepped into the room; by the time he got to the other side of the bed to help, Resident#1 slipped out of the sling (pad). CNA #2 stated that he was aware that two persons were needed for transfer with any lift used for any resident. There was no reasoning from CNA#1 on why she attempted to operate the lift alone. When resident #1 fell out of the lift, there were only 2 straps attached. CNA#1 was interviewed on 7/26/18 at 12:30PM, she stated that Resident #1 fell from the mechanical lift. She hooked the four straps of the mechanical lift pad to the lift unfortunately one on the right side did not hook properly, it's my job to see if the strap is hooked properly, I was rushing. CNA #1 stated that there was no one available to help her. Two people were needed for a mechanical lift transfer; CNA #2 was passing by when CNA #1 was placing the straps on the mechanical lift and she called him for help. CNA #1 did not tell CNA #2 what she wanted him to do. CNA #1 confirmed that the mechanical lift was operated by her only. CNA#1 stated when she was lifting the resident the base of the mechanical lift was in close position and should have been opened for stability. She moved the mechanical lift and resident#1 fell to the floor. The Assistant Director of Nursing Services(ADNS) was interviewed on 7/26/18 at 1:00 PM she stated, a statement was taken from CNA#2. He stated while walking in the hallway, he passed by a room where he noticed CNA#1 attempting to operate the mechanical lift alone. He went in voluntarily to help her. By the time he got in the room and tried to place himself on the other side of the resident, the resident was on the floor. CNA#1 stated that CNA#2 was in the room with her. When the ADNS went to assess the resident, the mechanical lift was in a high position. Resident (#1) was laying across the legs of the base of the mechanical lift. The left lower strap of the sling was not attached to the mechanical lift. CNA #3, CNA #4, CNA #5 and LPN #1 were interviewed on 7/26/18 at various times and stated that CNA #1 did not approach them for assistance with the transfer for the resident. 415.4(b)

Plan of Correction: ApprovedAugust 17, 2018

I- Resident #1 remains in the facility in stable condition.
A) CNA #1 was provided with a 1:1 in-service by the in-service coordinator regarding the facility's Policy and Procedure on Prohibition of Abuse, Neglect, Mistreatment and Misappropriation of Resident Property. CNA #1 was also provided with a 1:1 in-service by the in-service coordinator regarding the facility's Policy and Procedure on Mechanical Lifts. A return demonstration for competency was observed and noted. 7/19/2018
II- All residents in the facility that require a mechanical lift have the potential to be affected by this practice. All Certified Nursing Assistants were re-in serviced by the in-service coordinator regarding the facility's Policy and Procedure on Prohibition of Abuse, Neglect, Mistreatment and Misappropriation of Resident Property. All CNA's were re-in-serviced by the in-service coordinator on the facility Policy and Procedure on Mechanical Lifts. 7/31/2018
III- To ensure the highest standard of care is maintained and to prevent reoccurrence, the following measures have been implemented:
A) All CNA's will continue to be required to demonstrate competency of mechanical lifts on an annual basis by the in-service coordinator. 1:1 in-services will be provided as needed.
B) Competency of mechanical lift usage will be part of the orientation program of all newly hired Certified Nursing Assistants and will be part of the annual in-service for all nursing staff. 9/21/2018
IV- As part of the Quality Improvement Program, an audit tool was created to monitor compliance of all CNA's with the facility Policy and Procedure on Mechanical Lifts. The audit will be conducted by the in-service coordinator/designee monthly for the next 3 months and then quarterly for the next 2 quarters. All negative findings will immediately be reported to the Director of Nursing Services. Audit results will be reviewed during the Quarterly Improvement Meeting for the next 2 quarters. 9/21/2018
V- The DNS/ADNS will be responsible for the correction of the deficient practice. 9/21/2018